Gynaec .

history & examination

Dr.Sareena GIlvaz
Prof & HOD OBG
JMMC & RI
Name age occupation edu. socio -eco status
•Nulli/multi parous (no obst.score)
•Complaints in chronological order:
1.
2.
3.
•H/o present illness
1.duration,asso.sym,(general syms.wt.loss,wt.gain.fatigue,appetite
2.
3.
Asso.positive history & relevant neg.history
•Menstrual history: Regularity ,flow ,duration ,frequency,LMP
Normal cycles 24-38 days, flow 8  days, quantity 30-35ml(>80ml-HMB)

Old terminology : Menorrhagia, metrorrhagia

Polymenorrhagia
Oligomenorrhoea
DUB

Menopause - age symptoms --------

•Marital & Obstetric history:
FTND /CS/LCB-----
Contraception
Sterilisation(interval - concurrent -PP sterilisation)
Past history -----medical ------ drugs ,indications -HT,Diabetes,CAD---
Surgical ------D& C,Polypectomy,Myomectomy,Sling---
Family History - If relevant -endometriosis ,fibroids ,PCOS ,familial
cancers ---
•Personal history----Diet,Appetite,sleep,bowel,bladder

Addictions- smoking,alcohol,drug abuse

Occupational & social history if relevant

 General examination
•Height weight BMI
•BP Pulse resp. temp. gait
•Pallor Pedal odema Lymph nodes- (supra-cla.axillary,inguinal)
•Hirsuitism acanthosis ----
•secondary sexual characteristics(adolescent,primary amenorrhoea)
•Thyroid ,breast,skin,nail ,hair,clubbing cyanosis------

•Other systems--------- CVS RS CNS GI etc.......

 Examination of abdomen
• Is done with bladder empty
• With patient lying flat on her back with legs extended and good light
• The patient is bared from xiphi sternum to pubic sym. & flanks
exposed
 Examination of abdomen
•Inspection
Condition of skin - tense,stretched ,shiny,pigmented,reddish,any
engorgement of veins & striae - indicative of previous preg.

•Position of umbilicus
Normal midway between xiphi sternum & pubic sym.
Umblicus displaced down by ascites( Tanyol's sign)
Umblicus displaced up by swelling arising from pelvis
•Umbilicus everted - ascites
•Umbilicus tucked in -obesity
•Umblicus pushed to opposite side - swelling on one side of abdomen
Moving with respiration

•Any tumour arising from liver

gall bladder
stomach
spleen moves with resp.

Tumours from kidney do not move with resp.

Mass moving vertically with respiration is an intra abdominal
mass. (done with arms folded)
 Scar
• Linear scar (healed by primary intension )
• Broad & irregular scar (healed by secondary intension- indi. wound
inf.)
Palpation
•Mass-position in relation to nine quadrants of abdomen
Size
Shape
Surface
Margins
Consistency
Tenderness
Mobility -hold the swelling and move vertical & horizontal
• Mass arising from pelvis
• This terminology is used when the lower border cannot be
palpated or you cannot get below the swelling

• Midline masses arising from the uterus can be expressed in

terms of gravid uterus in weeks.
 Ballotma
• One hand is placed behind the loin & the other hand in front of the
abdomen and the swelling is moved antero-posteriorly between the
two hands
To differentiate parietal from intra abdominal
mass
•Head raising test- for masses above umbilicus
• Leg raising test -for masses below umbilicus

If mass more prominent - parietal mass

If mass less prominent -intra abdominal mass
Retroperitoneal mass
Patient on all fours:
•Mass falling forwards present - intra abdominal mass
•Mass not falling forwards - retroperitoneal mass
Swelling pulsatile or not :
1. Transmitted pulsation if in front of abdominal aorta
2.Expansile pulsation - if aneurysm
 To palpate for liver :
•Start from RIF with fingers parallel to right costal margin
•Patient taking deep breaths in and out
•Cannot insinuate your hand for both a palpable liver and spleen
•But can insinuate your hands if its kidney mass (insinuate between
swelling and costal margin)
•Palpate to see if liver which is enlarged for its upper limit by
percussion 4th intercostal space MAL

•Spleen same as liver.It should be twice its size to be palpable

 Percussion
• Mass arising from a solid organ - dull
• If coils of intestines over lie the swelling ,the percussion note is
resonant. ( like a band of colonic resonance)
• If ovarian cyst dull over mass in the center and does not change with
position of patient.
• Large ascites fluid thrill is present. Dullness over flank and its
shifts as patient rolls over.
• Shifting dullness:-when free fluid is suspected (500ml)
•Auscultation -
1.BS absent -peritonitis
2.BS exaggerated - intestinal obstruction
3.Bruit - when over highly vascular tumour
•Sims left lateral position - the left leg is extended and the
right leg flexed at hip and knees against the anterior abd.wall.

•This is useful in PRs, examination of perianal area ,urinary

fistulas in anterior vag.wall and demonstration of enterocele.
 Pelvic examination
•Pelvic examination includes :
1.Speculam examination
2.Bimannual digital pelvic examination

Empty bladder
Inform patient what to except
Adequate lighting
Patient in dorsal position
 Examination of vulva
•Look at mons pubis
Labia majora
Labia minora
Clitoris
Perineum & perineal body

Check skin for lesions ,ulcers ,scratch marks , caked up secretions

swelling , growth etc

Oestrogenised vulva seen in younger patients

Atrophic in postmenopausal women
 Speculum examination
• Sims speculum - patient brought to edge of table and asst.holds it
• Cuscos speculum -self retaining - but hides anterior & posterior vagina
• Lubricate & use it except in papsmear and high vaginal swab
• Insert speculum in the slit of the vagina & rotate it through 90 0 so that
its transverse diameter lies in the transverse diameter of the vagina
 S/E
• Take a pap smear (not if patient bleeding & if no obvious infection.)
• Check for SUI(patient should have full bladder)
• Normal vagina is moist ,pink & with rugosity
• Check for any infections -candida,TV,BV
• Check for gartners cyst (anterolateral vagina),bartholin cyst(lower
labia)
• Check anterior / mid /posterior compartment prolapse
• If any prolapse describe it & if any decubitus ulcer
 S/E
•Check cervix - you see the portio vaginalis portion only
•Take a pap smear
•If there is infection - high vaginal swab
•See squamo -columnar junction between dull pink squamous
epithelium of portio vaginalis & the bright red columinar epithelium of
endo cervix.
•This is normally located around the external os - reproductive age
inside the endocervix - postmenopausal
• Check for cervical polyps, nabothian cysts,ulcers growths
• Look at os & for secretions through that, including bleeding thro. os .
 P/V
• After S/E do a pv :
• Cervix is palpated for position , direction ,texture & if movements
painful
• After describing cervix tell about the uterus.
• Eg.cervix directed posteriorly in uterus anterverted position.
• The other hand over the abdomen at bimanual examination is done
to see uterine size, tenderness, mobility ,fixity etc as gently as
possible .
•Check for transmitted mobility if it is uterine mass
•Then check lateral fornices for adnexal mass ,size ,consistency,
tenderness & mobility.
•Normal tubes & ovaries are usually not palpable
•Groove signs is present between uterus and mass - if adnexal mass

Tender nodularity of cul-de-sac or uterosacrals - endometriosis

non tender nodules characteristic of malignant deposits
Bidigital examination :
• Check perineal body
•Rectovaginal spectum
•POD nodules
 Rectal examination
• Note anal sphincter tone
• Anal / rectal mucosa .Ano rectal ring - 3cms from anal verge -
junction between anal canal and rectum
• Anteriorly look for nodularity in POD by fully inserting finger on PR
• Hook your fingers for rectocele
• Check for parametrial involvement both sides laterally
• Patient with fissures have spasm and hence complain of
severe pain during digital examination.

• Intestinal obstruction -ballooning of rectum on PR

Summary & Diagnosis